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Alexander S. Rosemurgy - One of the best experts on this subject based on the ideXlab platform.
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Videoscopic Heller Myotomy with intraoperative endoscopy promotes optimal outcomes.
Jsls-journal of The Society of Laparoendoscopic Surgeons, 2020Co-Authors: Bloomston M, Brady P, Alexander S. RosemurgyAbstract:Minimally invasive surgical techniques are applicable to achalasia, but the optimum approach to intraoperative assessment of adequacy of Myotomy remains unestablished. We set out to show that videoscopic Heller Myotomy with concurrent endoscopy ensures adequacy of Myotomy while limiting postoperative clinically apparent reflux. Seventy-eight consecutive patients with achalasia underwent videoscopic Heller Myotomy with concomitant endoscopy between 1992 and 1998. Fundoplication was not routinely undertaken. Preoperative symptoms consisted of dysphagia (100%), emesis/regurgitation (68%), heartburn (58%), and postprandial chest pain (49%). Following Myotomy, significant improvement (P < 0.0001) was seen in dysphagia (43%), postprandial chest pain (13%), and emesis/regurgitation (9%) at a mean follow-up of 33+/-2.2 months. Mean reflux score (scale 0 to 5) improved from 3.7+/-0.3 to 1.5+/-0.2 (P < 0.0001). Improvement in symptoms was reported in 96% of patients. Fundoplication was used in 8 patients as part of hiatus reconstruction (n = 6) or repair of esophageal perforation (n = 2). Intraoperative endoscopy during videoscopic Heller Myotomy guides the extent and adequacy of Myotomy. By utilizing a focused dissection with preservation of the natural antireflux mechanisms around the gastroesophageal junction and limiting the extent of Myotomy along the cardia, postoperative reflux symptoms are minimized. We advocate concomitant endoscopy during Heller Myotomy to guide Myotomy and submit that routine fundoplication is clinically unnecessary.
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The "learning curve" in videoscopic Heller Myotomy.
Jsls-journal of The Society of Laparoendoscopic Surgeons, 2020Co-Authors: Mark Bloomston, Francesco M. Serafini, Boyce Hw, Alexander S. RosemurgyAbstract:In the early 1990s, minimally invasive videoscopy was applied to numerous operations. After undertaking more than 50 "open" Heller myotomies, our experience with videoscopic Heller Myotomy began in 1992. We sought to determine whether the outcome following videoscopic Heller Myotomy is influenced by surgeon experience. Seventy-eight patients with severe dysphagia secondary to achalasia underwent videoscopic Heller Myotomy between 1992 and 1998. Intraoperative endoscopy was utilized to ensure adequate Myotomy in all patients. Patients were stratified into 3 groups: the first 25 patients (group I), the second 25 patients (group II), and the last 28 patients (group III). Clinical outcome was based on length of stay, incidence of intraoperative complications, conversion to an 'open' procedure, and postoperative symptoms. Perioperative complications occurred in 20% of patients in group I compared with 8% and 12% in groups II and III, respectively (P = NS). Only 3 patients required conversion to an 'open' procedure, all in group I (P <0 .05). Symptomatic improvement was achieved in 80% of patients in group I, 100% in group II, and 96% in group III (P < 0.05). Significant reductions in conversions to open, length of stay, and postoperative symptoms were seen after 20 myotomies were undertaken. Outcome following videoscopic Heller Myotomy, like other videoscopic operations, improves as surgeons progress along the videoscopic "learning curve." After approximately 20 videoscopic Heller myotomies, surgeons can expect fewer conversions to open procedures, shorter hospital stays, and better symptomatic relief.
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Robotic Heller Myotomy
Robotic-Assisted Minimally Invasive Surgery, 2018Co-Authors: Sharona B. Ross, Darrell Downs, Iswanto Sucandy, Alexander S. RosemurgyAbstract:Achalasia is a rare esophageal dysmotility disorder of unknown etiology that affects approximately 1 in 100,000 people. It is characterized by haphazard contractility or absent peristalsis of the esophagus and uncoordinated relaxation of a hypertensive lower esophageal sphincter (LES) mechanism. The combination of esophageal dysmotility and uncoordinated LES relaxation produces the debilitating symptoms of achalasia, i.e., symptoms of esophageal outlet obstruction (e.g., dysphagia with liquids and solids and regurgitation, aspiration), as well as other symptoms associated with esophageal spasm, like chest pain. Treatment for achalasia has evolved considerably over the past 30 years. From thoracotomies and celiotomies to endoscopic techniques (e.g., pneumatic balloon dilations and botulinum toxin injections and, most recently, POEM) to minimally invasive surgical techniques (e.g., laparoscopic Myotomy, to laparo-endoscopic single-site [LESS] Myotomy, to robotic Myotomy). Today, Heller Myotomy is considered the “gold standard” therapy for achalasia, alleviating symptoms by defunctionalizing the lower esophageal sphincter mechanism. We have undertaken Heller Myotomy on over 700 patients. Herein, we outline our surgical technique for robotic Heller Myotomy, which is based upon this experience.
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Laparoscopic Heller Myotomy with Anterior Fundoplication Improves Frequency and Severity of Symptoms of Achalasia, Regardless of Preoperative Severity Determined by Esophagography.
American Surgeon, 2018Co-Authors: Alexander S. Rosemurgy, Darrell Downs, Luberice K, Forat Swaid, Christian Rodriguez, Patel K, Paul Toomey, Sharona B. RossAbstract:This study was undertaken to determine whether postoperative outcomes after laparoscopic Heller Myotomy with anterior fundoplication could be predicted by preoperative findings on esophagography. Preoperative barium esophagograms of 135 patients undergoing laparoscopic Heller Myotomy with anterior fundoplication were reviewed. The number of esophageal curves, esophageal width, and angulation of the gastroesophageal junction (GEJ) were determined; correlations between these determined parameters and symptoms were assessed using linear regression analysis. The number of esophageal curves correlated with the preoperative frequency of dysphagia, vomiting, chest pain, regurgitation, and heartburn. The width of the esophagus negatively correlated with the preoperative frequency of regurgitation. The angulation of the GEJ did not correlate with preoperative symptoms. Laparoscopic Heller Myotomy with anterior fundoplication significantly reduced the frequency and severity of all symptoms, regardless of the number of esophageal curves, esophageal width, or angulation of the GEJ. Laparoscopic Heller Myotomy with anterior fundoplication provides dramatic palliation for achalasia. More esophageal curves on preoperative esophagography correlate well with the frequency of a broad range of preoperative symptoms, including the frequency of dysphagia and regurgitation. Patients experience dramatically improved frequency and severity of symptoms after laparoscopic Heller Myotomy with anterior fundoplication for achalasia regardless of the number of esophageal curves, esophageal width, or the angulation of the GEJ. Findings on barium esophagogram, in evaluating achalasia, should not deter the application of laparosocopic Heller Myotomy with anterior fundoplication.
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Dissatisfaction after Laparoscopic Heller Myotomy: The Truth is Easy to Swallow
American Journal of Surgery, 2017Co-Authors: Alexander S. Rosemurgy, Darrell Downs, Carrie E. Ryan, Gianvanna Jadick, Forat Swaid, Kenneth Luberice, Sharona B. RossAbstract:Abstract Background Although laparoscopic Heller Myotomy has been shown to well palliate symptoms of achalasia, we have observed a small subset of patients who are “Dissatisfied”. This study was undertaken to identify the causes of their dissatisfaction. Study design Patients undergoing laparoscopic Heller Myotomy from 1992 to 2015 were prospectively followed. Using a Likert scale, patients rated their symptom frequency/severity before and after the procedure. Patients graded their experience from “Very Satisfying” to “Very Unsatisfying.” Results 647 patients underwent laparoscopic Heller Myotomy. Fifty (8%) patients, median age 57 years and BMI 24 kg/m 2 reported dissatisfaction at follow-up subsequent to Myotomy. “Dissatisfied” patients were more likely to have undergone prior abdominal operations (p = 0.01) or previous myotomies (p = 0.02). “Dissatisfied” patients had a greater incidence of diverticulectomy (p = 0.03) and had longer postoperative LOS (p = 0.01). Symptom frequency/severity persisted after Myotomy for dissatisfied patients (p > 0.05). Conclusion Dissatisfaction after laparoscopic Heller Myotomy is directly related to persistent/recurrent symptoms. Previous abdominal operations/myotomies, diverticulectomies, and longer LOS are predictors of dissatisfaction. With this understanding, we can identify patients who might be more prone to dissatisfaction.
Santiago Horgan - One of the best experts on this subject based on the ideXlab platform.
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Robotic-Assisted Heller Myotomy
Telesurgery, 2020Co-Authors: Yoav Mintz, Santiago HorganAbstract:Laparoscopic Heller Myotomy (LHM) has become the standard treatment option for achalasia. Evidence-based medicine has shown surgical treatment to be the most effective option due to the long-term improvement of symptoms following surgery [5, 6, 13, 20–23]. However, other treatment options are still practiced either due to unavailable surgical expertise or due to patient comorbidities, which prohibit general anesthesia. Recently, robotic-assisted Heller Myotomy (RAHM) has been shown to be superior to LHM in terms of safety and comparable with LHM in outcome [14].
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laparoscopic Heller Myotomy for achalasia facilitated by robotic assistance
Surgical Endoscopy and Other Interventional Techniques, 2006Co-Authors: Carlos A Galvani, Maria V Gorodner, F Moser, M Baptista, Phillip Donahue, Santiago HorganAbstract:Background Laparoscopic Heller Myotomy is the standard operation for achalasia. The incidence of esophageal perforation is approximately 5% to 10%. Data about the safety and utility of robotically assisted Heller Myotomy (RAHM) are scarce. The aim of this study was to assess the efficacy and safety of RAHM for the treatment of esophageal achalasia.
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Robotic-assisted Heller Myotomy versus laparoscopic Heller Myotomy for the treatment of esophageal achalasia: multicenter study
Journal of Gastrointestinal Surgery, 2005Co-Authors: Santiago Horgan, Maria V Gorodner, Carlos Galvani, Pablo Omelanczuck, Fernando Elli, Federico Moser, Luis Durand, Miguel Caracoche, Jorge Nefa, Sergio BustosAbstract:Laparoscopic Heller Myotomy (LHM) has become the standard treatment option for achalasia. The incidence of esophageal perforation reported is about 5%–10%. Robotically assisted Heller Myotomy (RAHM) is emerging as a safe alternative to LHM. Data comparing the two approaches are scant. The aim of this study was to compare RAHM with LHM in terms of efficacy and safety for treatment of achalasia. A total of 121 patients underwent surgical treatment of achalasia at three institutions. A retrospective review of prospectively collected perioperative data was performed. Patients were divided into two groups: group A (RAHM), 59 patients, and group B (LHM), 62 patients. All the operations were completed using minimally invasive techniques. There were 63 women and 58 men, with a mean age of 45 ±19 years (14–82 years). Fifty-one percent of patients in group A and 95% of patients in group B reported weight loss. Duration of symptoms was equal for both groups. Dysphagia was the main complaint in both groups (P = NS). There was no difference in preoperative endoscopic treatment in both groups (44% versus 27%, P = NS). Operative time was significantly shorter for LHM in the first half of the experience (141 ± 49 versus 122 ± 44 minutes, P < .05). However, in the last 30 cases there was no difference in operative time between the groups (P = NS). Intraoperative complications (esophageal perforation) were more frequent in group B (16% versus 0%). The incidence of postoperative heartburn did not differ by group. There were no deaths. At 18 and 22 months, 92% and 90% of patients had relief of their dysphagia. This study suggests that RAHM is safer than LHM, because it decreases the incidence of esophageal perforation to 0%, even in patients who had previous treatment. At short-term follow-up, relief of dysphagia was equally achieved in both groups.
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computer enhanced robotic telesurgery minimizes esophageal perforation during Heller Myotomy
Surgery, 2005Co-Authors: Scott W Melvin, John M Dundon, Mark A Talamini, Santiago HorganAbstract:Background Laparoscopic Heller Myotomy has emerged as the treatment of choice for achalasia. However, intraoperative esophageal perforation remains a significant complication. Computer-enhanced operative techniques have the potential to improve outcomes for certain operative procedures. Robotic, computer-enhanced laparoscopic telemanipulators using 3-dimensional magnified imaging and motion scaling are designed uniquely to facilitate certain operations requiring fine-tissue manipulation. We hypothesized that computer-enhanced robotic Heller Myotomy would reduce intraoperative complications compared with laparoscopic techniques. Methods All patients undergoing an operation for achalasia at 3 institutions with a robotic surgery system (DaVinci; Intuitive Surgical Corporation, Sunnyvale, Calif) were followed-up prospectively. Demographics, perioperative course, complications, and hospital stay were recorded. Follow-up evaluation was obtained via a standardized symptom survey, office visits, and medical records. Data were compared with preoperative symptoms using a Mann-Whitney U test, and operating times were compared using the ANOVA test. Results Between August 2000 and August 2004 there were 104 patients who underwent a robotic Heller Myotomy with partial fundoplicaton. There were 53 women and 51 men. All patients were symptomatic. The operative time was 140.55 minutes overall, but improved from 162.63 minutes to 113.50 minutes from 2000-2002 to 2003-2004 ( P = .0001). There were no esophageal perforations. There were 8 minor complications and 1 patient required conversion to an open operation. Sixty-six (62.3%) patients were discharged on the first postoperative day and the average hospital stay was 1.5 days. A symptom survey was completed in 79 of 104 patients (76%) at follow-up evaluation. Symptoms improved in all patients with an average follow-up symptom score of 0.48 compared with 5.0 before the operation ( P = .0001). Forty-three of the 79 patients from whom follow-up data were collected had a minimum follow-up period of 1 year. The follow-up period averaged 16 months. No patients required reoperation. Conclusions Computer-enhanced robotic laparoscopic techniques provide a clear advantage over standard laparoscopy for the operative treatment of achalasia. We have shown in this large series that Heller Myotomy can be completed using this technology without esophageal perforation. The application of computer-enhanced operative techniques appears to provide superior outcomes in selected procedures.
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Laparoscopic Heller Myotomy and Dor Fundoplication for Achalasia in Children
Pediatric Endosurgery and Innovative Techniques, 1999Co-Authors: John H.t. Waldhausen, Santiago Horgan, Carlos A. PellegriniAbstract:ABSTRACT The surgical treatment of achalasia offers patients excellent results; however, surgery is often recommended only after multiple failed attempts at nonoperative management. The authors review their experience with laparoscopic Heller Myotomy and Dor fundoplication in children. This is a retrospective review of eight consecutive children with achalasia who underwent laparoscopic Heller Myotomy and Dor fundoplication. The average age was 14.5 years (range 11–17). Symptoms were documented by a severity score. Operative time, complications, outcome, and patient satisfaction were examined. All eight children had high-grade symptoms. All were evaluated preoperatively with upper gastrointestinal series and manometry, and the findings were consistent with achalasia. The laparoscopic procedure with Dor fundoplication was used for all eight children. The results have been excellent with minimal complications, resolution of preoperative symptoms, and hospital stays of 2 days in seven of eight patients. Pati...
Michael D Holzman - One of the best experts on this subject based on the ideXlab platform.
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Heller Myotomy versus Heller Myotomy with dor fundoplication for achalasia long term symptomatic follow up of a prospective randomized controlled trial
Surgical Endoscopy and Other Interventional Techniques, 2018Co-Authors: Kristy Kummerow Broman, William O Richards, Kenneth W Sharp, Richard A Pierce, Sharon Phillips, Adil Faqih, Joan L Kaiser, Benjamin K Poulose, Michael D HolzmanAbstract:Background Our prior randomized controlled trial of Heller Myotomy alone versus Heller plus Dor fundoplication for achalasia from 2000 to 2004 demonstrated comparable postoperative resolution of dysphagia but less gastroesophageal reflux after Heller plus Dor. Patient-reported outcomes are needed to determine whether the findings are sustained long-term.
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Heller Myotomy versus Heller Myotomy with dor fundoplication for achalasia a prospective randomized double blind clinical trial
Annals of Surgery, 2004Co-Authors: William O Richards, Alfonso Torquati, Michael D Holzman, Leena Khaitan, Daniel W Byrne, Rami Lutfi, Kenneth W SharpAbstract:Since the first report of laparoscopic Heller Myotomy in 1991 by Shimi et al1 and thoracoscopic Heller Myotomy by Pellegrini et al2 in 1992, minimally invasive techniques have been increasingly used for the treatment of achalasia. Many surgeons have noticed a distinct change in the referral patterns for treatment of achalasia now that minimally invasive techniques are available. Patti and colleagues3 in 2002 reported that during the past decade, their center at the University of California, San Francisco, saw a marked increase in the number of patients who were referred for laparoscopic Heller Myotomy with a corresponding decrease in use of pneumatic balloon dilation or botulinum toxin injection. Laparoscopic Heller Myotomy is the preferred treatment at Vanderbilt, and we have previously reported our results and technique.4 A great deal of controversy exists over the appropriate use of antireflux procedures to prevent reflux after Myotomy. The arguments for using a partial antireflux procedure with laparoscopic Heller Myotomy have been summarized nicely by Peters,5 and the arguments against the routine use of an antireflux procedure were presented by our group during a Society for Surgery of the Alimentary Tract symposium in 2000.6 A recent meta-analysis of laparoscopic Heller Myotomy with or without antireflux procedure from 1991 to 2001 was performed by Lyass et al.7 Pathologic acid exposure was identified by 24-hour pH studies in 7.9% of 489 patients who underwent Heller with partial fundoplication. Forty-seven patients who had previously undergone Heller without antireflux procedure were studied with 24-hour pH monitoring and only 4, or 10%, of the 40 patients had pathologic acid exposure. This meta-analysis concluded “based on the reported data in human subjects that no recommendations could be made regarding the efficacy of partial antireflux procedures in protecting against pathologic gastroesophageal reflux (GER) after esophageal Heller Myotomy.” We have completed a study that randomized 43 patients with achalasia to Heller Myotomy alone or to Heller Myotomy plus Dor fundoplication. The study was designed as a double-blind, parallel-group randomized trial to test the null hypothesis that the addition of Dor fundoplication will not alter the incidence of pathologic GER in these patients.
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an antireflux procedure should not routinely be added to a Heller Myotomy
Journal of Gastrointestinal Surgery, 2001Co-Authors: William O Richards, Kenneth W Sharp, Michael D HolzmanAbstract:Achalasia is a disease that can only be palliated, not corrected, by surgery. The philosophy at Vanderbilt has been to maximize the relief of dysphagia through Myotomy that is measured using intraoperative endoscopy while minimizing the mechanical factors that may increase gastroesophageal reflux. Only a few of our patients (3 [ 13 %] of 24) have developed pathologic reflex after Heller Myotomy without an antireflux procedure, and all have been treated medically with excellent results. The addition of an antireflux procedure would inappropriately treat the 87% of patients who have no objective measurement of gastroesophageal reflux. Because gastroesophageal reflux does occur in patients who have undergone Heller Myotomy and Dor fundoplication, we have chosen not to add a procedure that may increase dysphagia. Our argument against the routine use of fundoplication rests on the concept that a fundoplication, either total or partial, increases resistance to flow across the LES and therefore decreases symptom relief. Our studies, as well as others, indicate that esophageal clearance is an important aspect of reflux after Heller Myotomy, and postoperatively patients with achalasia are more prone to long periods of acid exposure caused by inadequate clearance. Symptoms of GERD in patients with achalasia do not correlate with objective measurements of acid exposure in the esophagus; therefore they cannot be used to follow up patients after Heller Myotomy. Gastroesophageal reflux can be a significant problem in patients whether they have undergone Heller Myotomy alone or Heller Myotomy plus fundoplication. We recommend 24-hour pH studies to monitor acid exposure in the distal esophagus postoperatively to identify pathologic GERD after Heller Myotomy. Patients found to have pathologic reflux after Heller Myotomy with or without fundoplication should be treated medically. In short, acid reflux after a Myotomy can be controlled simply with medication, but dysphagia requires more drastic and potentially hazardous treatment such as pneumatic dilatation or reoperation.
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prevalence of gastroesophageal reflux after laparoscopic Heller Myotomy
Surgical Endoscopy and Other Interventional Techniques, 1999Co-Authors: William O Richards, Michael D Holzman, Ronald H Clements, P C Wang, Christopher D Lind, H Mertz, J K Ladipo, Kenneth W SharpAbstract:Background: There is still some controversy over the need for antireflux procedures with Heller Myotomy in the treatment of achalasia. This study was undertaken in an effort to clarify this question.
Kenneth W Sharp - One of the best experts on this subject based on the ideXlab platform.
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Heller Myotomy versus Heller Myotomy with dor fundoplication for achalasia long term symptomatic follow up of a prospective randomized controlled trial
Surgical Endoscopy and Other Interventional Techniques, 2018Co-Authors: Kristy Kummerow Broman, William O Richards, Kenneth W Sharp, Richard A Pierce, Sharon Phillips, Adil Faqih, Joan L Kaiser, Benjamin K Poulose, Michael D HolzmanAbstract:Background Our prior randomized controlled trial of Heller Myotomy alone versus Heller plus Dor fundoplication for achalasia from 2000 to 2004 demonstrated comparable postoperative resolution of dysphagia but less gastroesophageal reflux after Heller plus Dor. Patient-reported outcomes are needed to determine whether the findings are sustained long-term.
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Heller Myotomy vs Heller Myotomy plus dor fundoplication cost utility analysis of a randomized trial
Surgical Endoscopy and Other Interventional Techniques, 2006Co-Authors: Alfonso Torquati, Leena Khaitan, Rami Lutfi, Kenneth W Sharp, William O RichardsAbstract:Background The addition of a Dor antireflux procedure reduces the risk of pathologic gastroesophageal reflux (GER) by ninefold following laparoscopic Heller Myotomy for achalasia. It is not clear, however, how these benefits compare with the increased cost of the fundoplication. The objective of this study was to estimate the cost-effectiveness of Heller Myotomy plus Dor fundoplication compared with Heller alone in patients with achalasia.
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Heller Myotomy versus Heller Myotomy with dor fundoplication for achalasia a prospective randomized double blind clinical trial
Annals of Surgery, 2004Co-Authors: William O Richards, Alfonso Torquati, Michael D Holzman, Leena Khaitan, Daniel W Byrne, Rami Lutfi, Kenneth W SharpAbstract:Since the first report of laparoscopic Heller Myotomy in 1991 by Shimi et al1 and thoracoscopic Heller Myotomy by Pellegrini et al2 in 1992, minimally invasive techniques have been increasingly used for the treatment of achalasia. Many surgeons have noticed a distinct change in the referral patterns for treatment of achalasia now that minimally invasive techniques are available. Patti and colleagues3 in 2002 reported that during the past decade, their center at the University of California, San Francisco, saw a marked increase in the number of patients who were referred for laparoscopic Heller Myotomy with a corresponding decrease in use of pneumatic balloon dilation or botulinum toxin injection. Laparoscopic Heller Myotomy is the preferred treatment at Vanderbilt, and we have previously reported our results and technique.4 A great deal of controversy exists over the appropriate use of antireflux procedures to prevent reflux after Myotomy. The arguments for using a partial antireflux procedure with laparoscopic Heller Myotomy have been summarized nicely by Peters,5 and the arguments against the routine use of an antireflux procedure were presented by our group during a Society for Surgery of the Alimentary Tract symposium in 2000.6 A recent meta-analysis of laparoscopic Heller Myotomy with or without antireflux procedure from 1991 to 2001 was performed by Lyass et al.7 Pathologic acid exposure was identified by 24-hour pH studies in 7.9% of 489 patients who underwent Heller with partial fundoplication. Forty-seven patients who had previously undergone Heller without antireflux procedure were studied with 24-hour pH monitoring and only 4, or 10%, of the 40 patients had pathologic acid exposure. This meta-analysis concluded “based on the reported data in human subjects that no recommendations could be made regarding the efficacy of partial antireflux procedures in protecting against pathologic gastroesophageal reflux (GER) after esophageal Heller Myotomy.” We have completed a study that randomized 43 patients with achalasia to Heller Myotomy alone or to Heller Myotomy plus Dor fundoplication. The study was designed as a double-blind, parallel-group randomized trial to test the null hypothesis that the addition of Dor fundoplication will not alter the incidence of pathologic GER in these patients.
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an antireflux procedure should not routinely be added to a Heller Myotomy
Journal of Gastrointestinal Surgery, 2001Co-Authors: William O Richards, Kenneth W Sharp, Michael D HolzmanAbstract:Achalasia is a disease that can only be palliated, not corrected, by surgery. The philosophy at Vanderbilt has been to maximize the relief of dysphagia through Myotomy that is measured using intraoperative endoscopy while minimizing the mechanical factors that may increase gastroesophageal reflux. Only a few of our patients (3 [ 13 %] of 24) have developed pathologic reflex after Heller Myotomy without an antireflux procedure, and all have been treated medically with excellent results. The addition of an antireflux procedure would inappropriately treat the 87% of patients who have no objective measurement of gastroesophageal reflux. Because gastroesophageal reflux does occur in patients who have undergone Heller Myotomy and Dor fundoplication, we have chosen not to add a procedure that may increase dysphagia. Our argument against the routine use of fundoplication rests on the concept that a fundoplication, either total or partial, increases resistance to flow across the LES and therefore decreases symptom relief. Our studies, as well as others, indicate that esophageal clearance is an important aspect of reflux after Heller Myotomy, and postoperatively patients with achalasia are more prone to long periods of acid exposure caused by inadequate clearance. Symptoms of GERD in patients with achalasia do not correlate with objective measurements of acid exposure in the esophagus; therefore they cannot be used to follow up patients after Heller Myotomy. Gastroesophageal reflux can be a significant problem in patients whether they have undergone Heller Myotomy alone or Heller Myotomy plus fundoplication. We recommend 24-hour pH studies to monitor acid exposure in the distal esophagus postoperatively to identify pathologic GERD after Heller Myotomy. Patients found to have pathologic reflux after Heller Myotomy with or without fundoplication should be treated medically. In short, acid reflux after a Myotomy can be controlled simply with medication, but dysphagia requires more drastic and potentially hazardous treatment such as pneumatic dilatation or reoperation.
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prevalence of gastroesophageal reflux after laparoscopic Heller Myotomy
Surgical Endoscopy and Other Interventional Techniques, 1999Co-Authors: William O Richards, Michael D Holzman, Ronald H Clements, P C Wang, Christopher D Lind, H Mertz, J K Ladipo, Kenneth W SharpAbstract:Background: There is still some controversy over the need for antireflux procedures with Heller Myotomy in the treatment of achalasia. This study was undertaken in an effort to clarify this question.
William O Richards - One of the best experts on this subject based on the ideXlab platform.
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Heller Myotomy versus Heller Myotomy with dor fundoplication for achalasia long term symptomatic follow up of a prospective randomized controlled trial
Surgical Endoscopy and Other Interventional Techniques, 2018Co-Authors: Kristy Kummerow Broman, William O Richards, Kenneth W Sharp, Richard A Pierce, Sharon Phillips, Adil Faqih, Joan L Kaiser, Benjamin K Poulose, Michael D HolzmanAbstract:Background Our prior randomized controlled trial of Heller Myotomy alone versus Heller plus Dor fundoplication for achalasia from 2000 to 2004 demonstrated comparable postoperative resolution of dysphagia but less gastroesophageal reflux after Heller plus Dor. Patient-reported outcomes are needed to determine whether the findings are sustained long-term.
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Heller Myotomy vs Heller Myotomy plus dor fundoplication cost utility analysis of a randomized trial
Surgical Endoscopy and Other Interventional Techniques, 2006Co-Authors: Alfonso Torquati, Leena Khaitan, Rami Lutfi, Kenneth W Sharp, William O RichardsAbstract:Background The addition of a Dor antireflux procedure reduces the risk of pathologic gastroesophageal reflux (GER) by ninefold following laparoscopic Heller Myotomy for achalasia. It is not clear, however, how these benefits compare with the increased cost of the fundoplication. The objective of this study was to estimate the cost-effectiveness of Heller Myotomy plus Dor fundoplication compared with Heller alone in patients with achalasia.
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Heller Myotomy versus Heller Myotomy with dor fundoplication for achalasia a prospective randomized double blind clinical trial
Annals of Surgery, 2004Co-Authors: William O Richards, Alfonso Torquati, Michael D Holzman, Leena Khaitan, Daniel W Byrne, Rami Lutfi, Kenneth W SharpAbstract:Since the first report of laparoscopic Heller Myotomy in 1991 by Shimi et al1 and thoracoscopic Heller Myotomy by Pellegrini et al2 in 1992, minimally invasive techniques have been increasingly used for the treatment of achalasia. Many surgeons have noticed a distinct change in the referral patterns for treatment of achalasia now that minimally invasive techniques are available. Patti and colleagues3 in 2002 reported that during the past decade, their center at the University of California, San Francisco, saw a marked increase in the number of patients who were referred for laparoscopic Heller Myotomy with a corresponding decrease in use of pneumatic balloon dilation or botulinum toxin injection. Laparoscopic Heller Myotomy is the preferred treatment at Vanderbilt, and we have previously reported our results and technique.4 A great deal of controversy exists over the appropriate use of antireflux procedures to prevent reflux after Myotomy. The arguments for using a partial antireflux procedure with laparoscopic Heller Myotomy have been summarized nicely by Peters,5 and the arguments against the routine use of an antireflux procedure were presented by our group during a Society for Surgery of the Alimentary Tract symposium in 2000.6 A recent meta-analysis of laparoscopic Heller Myotomy with or without antireflux procedure from 1991 to 2001 was performed by Lyass et al.7 Pathologic acid exposure was identified by 24-hour pH studies in 7.9% of 489 patients who underwent Heller with partial fundoplication. Forty-seven patients who had previously undergone Heller without antireflux procedure were studied with 24-hour pH monitoring and only 4, or 10%, of the 40 patients had pathologic acid exposure. This meta-analysis concluded “based on the reported data in human subjects that no recommendations could be made regarding the efficacy of partial antireflux procedures in protecting against pathologic gastroesophageal reflux (GER) after esophageal Heller Myotomy.” We have completed a study that randomized 43 patients with achalasia to Heller Myotomy alone or to Heller Myotomy plus Dor fundoplication. The study was designed as a double-blind, parallel-group randomized trial to test the null hypothesis that the addition of Dor fundoplication will not alter the incidence of pathologic GER in these patients.
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an antireflux procedure should not routinely be added to a Heller Myotomy
Journal of Gastrointestinal Surgery, 2001Co-Authors: William O Richards, Kenneth W Sharp, Michael D HolzmanAbstract:Achalasia is a disease that can only be palliated, not corrected, by surgery. The philosophy at Vanderbilt has been to maximize the relief of dysphagia through Myotomy that is measured using intraoperative endoscopy while minimizing the mechanical factors that may increase gastroesophageal reflux. Only a few of our patients (3 [ 13 %] of 24) have developed pathologic reflex after Heller Myotomy without an antireflux procedure, and all have been treated medically with excellent results. The addition of an antireflux procedure would inappropriately treat the 87% of patients who have no objective measurement of gastroesophageal reflux. Because gastroesophageal reflux does occur in patients who have undergone Heller Myotomy and Dor fundoplication, we have chosen not to add a procedure that may increase dysphagia. Our argument against the routine use of fundoplication rests on the concept that a fundoplication, either total or partial, increases resistance to flow across the LES and therefore decreases symptom relief. Our studies, as well as others, indicate that esophageal clearance is an important aspect of reflux after Heller Myotomy, and postoperatively patients with achalasia are more prone to long periods of acid exposure caused by inadequate clearance. Symptoms of GERD in patients with achalasia do not correlate with objective measurements of acid exposure in the esophagus; therefore they cannot be used to follow up patients after Heller Myotomy. Gastroesophageal reflux can be a significant problem in patients whether they have undergone Heller Myotomy alone or Heller Myotomy plus fundoplication. We recommend 24-hour pH studies to monitor acid exposure in the distal esophagus postoperatively to identify pathologic GERD after Heller Myotomy. Patients found to have pathologic reflux after Heller Myotomy with or without fundoplication should be treated medically. In short, acid reflux after a Myotomy can be controlled simply with medication, but dysphagia requires more drastic and potentially hazardous treatment such as pneumatic dilatation or reoperation.
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prevalence of gastroesophageal reflux after laparoscopic Heller Myotomy
Surgical Endoscopy and Other Interventional Techniques, 1999Co-Authors: William O Richards, Michael D Holzman, Ronald H Clements, P C Wang, Christopher D Lind, H Mertz, J K Ladipo, Kenneth W SharpAbstract:Background: There is still some controversy over the need for antireflux procedures with Heller Myotomy in the treatment of achalasia. This study was undertaken in an effort to clarify this question.